Psychiatric Assessment

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Psychiatric Assessment

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In the consultation, a GP has to make an initial assessment of the nature and severity of the problem and the risk to the individual and other people. The GP then formulates an initial management plan. The patient's concerns need to be taken seriously. Respect and empathy will help to build trust.

For many people presenting with mild psychiatric problems in primary care, it will not be necessary to explore every detail of the full psychiatric assessment outlined below. Often the initial priority is to develop a rapport and demonstrate a caring, supportive approach which can be further developed in future consultations.

The more experience GPs develop in dealing with patients with mental health problems, the easier it will become to pick up on non-verbal clues. As soon as they enter the consulting room, observe the patient's degree of personal grooming and hygiene and whether they make eye contact on greeting. Note whether they are appropriately dressed for the time of year and whether they are accompanied (indicating possible social support) or have come alone.

In more severe presentations of psychiatric illness, the priority is to assess quickly and minimise risk and to ensure appropriate access to mental health care resources as quickly as is necessary and appropriate.

Presenting complaint: elucidate the patient's priorities. Use open-ended questions but quickly narrow down on the diagnosis and look for supporting evidence. Find out:

The nature of the problem.

The date of onset and whether the onset was slow or sudden.

Why and precisely how the person presented at this time.

What precipitated the problem.

The severity and its course and effect on work and relationships, as well as physical effects on appetite, sleep and sexual drive.

Previous episodes, including dates, treatments and outcomes of similar episodes.

The description of the problem will also enable an assessment of the patient's insight into their situation. Some patients may deny the existence of a problem and it may be necessary to obtain a history of the illness from a family member or close friend.

Personal history: should cover many aspects of the individual's life, from early childhood. It should include:

Work history: jobs held, reasons for changing jobs, level of satisfaction with employment and ambitions. Assess what effect the illness will have on their job.

Marital history and also relationship history with others (intimate or sexual relationships). Establish whether there is anyone they currently feel able to confide in.

Family history: close family, including names, ages and their past and present mental and physical health.

Illegal activities/violence: criminal record and any previous episodes of violence or other acts of aggression.

Present social situation: establish what support they currently have at home.

Premorbid personality: note how the individual would describe his or her personality before becoming unwell. Establish the patient's overall mood or temperament - ie anxious, obsessional, solitary or social. If necessary, include detail on:

Character traits.

Confidence.

Religious and moral beliefs.

Ambitions and aspirations.

Social relationships with family, friends, workmates.

Alcohol and illicit drug misuse (past and present)..

Full current drug history (prescribed medications, self-prescribed, or recreational).

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